Provider Demographics
NPI:1548689904
Name:MODI, KUNJAL (MD)
Entity type:Individual
Prefix:
First Name:KUNJAL
Middle Name:
Last Name:MODI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 MOUNTAIN RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-3407
Mailing Address - Country:US
Mailing Address - Phone:973-747-8476
Mailing Address - Fax:
Practice Address - Street 1:203 PALISADE AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-1155
Practice Address - Country:US
Practice Address - Phone:201-653-5722
Practice Address - Fax:201-653-6340
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-14
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA10520900207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program